ATLANTA (FRONTLINE MEDICAL NEWS) – Among all deaths by suicide, 15%-20% are attributable to a previously undescribed entity that now has a name: acute suicidal affective disturbance, Thomas Joiner, Ph.D., said at the annual conference of the American Association of Suicidology.

“It’s real, it’s fairly common, and it’s extremely dangerous. We think it ranks up there among the most serious of conditions – more likely to result in death than the manic phase of bipolar disorder or schizophrenia, for example,” said Dr. Joiner, who first identified and characterized the condition, named it, plays a pivotal role in ongoing multicenter collaborative research efforts targeting it, and vows to see acute suicidal affective disturbance, or ASAD, included in the DSM-6.

ASAD is a concept compatible with Dr. Joiner’s “ Interpersonal Theory of Suicide,” which has taken the field of suicidology by storm. But ASAD , he stressed, is not a theoretical construct.

“ASAD exists as an entity, as a true object in nature that I worry over because it kills people and we can’t diagnose it currently because there’s a gap in the nomenclature. We’re proposing this condition to fill that gap,” explained Dr. Joiner, professor of psychology at Florida State University, Tallahassee.

Roughly 80% of all deaths by suicide can be attributed to a recognized mental health disorder, such as major depressive disorder, the depressive phase of bipolar disorder, anorexia nervosa, schizophrenia, or borderline personality disorder. Dr. Joiner presented highlights of three separate studies now in press – one conducted in Veterans Affairs outpatients, another in high-risk university undergraduates, and a third involving nearly 7,700 Mayo Clinic psychiatric inpatients and more than 3,400 U.S. Army high-risk patients – all of which support the construct validity of ASAD as a distinct entity that correlates negatively with impulsivity and is unrelated to alcohol use disorders or mood disorders.

In addition, Dr. Joiner continued, three different research teams – his own; the Military Suicide Research Consortium , which he codirects; and the U.S. Army STARRS group – have identified subgroups of patients at very high suicide risk who are characterized by ASAD symptoms that are discernible from those of established clinical entities (see list for proposed ASAD criteria).

“We intend to put ASAD into DSM-6. We know that’s going to be a battle, and we’re ready for it. We’re determined to fight it,” the psychologist said.

If ASAD were to eventually become a diagnosable condition, the clinical implications would be far-reaching, he observed. It would be a billable entity. Also, its existence in the formal psychiatric nomenclature would alert clinicians to be vigilant regarding ASAD; that’s crucial because recurrences can be lethal, and recognition of the prodromal overarousal symptoms may head off a full-blown crisis.

“If we’re right about ASAD, it would imply that mood disorders and ASAD are distinct, that their onset and remission patterns are different, thus supporting the rationale of suicide-specific treatments like CAMS [collaborative assessment and management of suicidality] and DBT [dialectical behavior therapy]. It would suggest the need for intensive and long-lasting therapies, because a recurrence can cost people their lives,” he continued.

Should ASAD become legitimized as a diagnosis, it would shore up the public health argument in favor of suicide-means restriction as a strategy for forestalling suicidal action.

“ASAD is a time-limited arousal state. You can’t sustain it for more than an hour or a few hours. It’ll abate with the passage of time,” according to Dr. Joiner.

In response to an audience question, he said it’s his clinical impression – not yet supported by data – that the most common comorbid conditions in patients with ASAD are anxiety disorders and personality disorders. Also, ASAD doesn’t appear to be age dependent: “We think it can emerge at any point in the lifespan.”

Dr. Joiner emphasized that many questions regarding ASAD remain unanswered.

“We have a long way to go,” he conceded. “And I’m not talking about years here, I’m talking about decades. The effort is going to be primarily research oriented. It’s a scientific effort. We’ve got to clear the hurdle scientifically, and we haven’t done that yet, although we’ve gotten a start.”

He reported having no financial conflicts regarding his presentation.

Proposed criteria for ASAD

1. A sudden surge in suicidal intent occurring over the course of minutes, hours, or days rather than weeks or months.

2. One or both of two alienation criteria: a) severe social withdrawal defined by extreme disgust with others or perceived liability to others; b) marked self-alienation manifested as self-disgust or the view that one’s selfhood is an onerous burden.

3. The perception that numbers 1 and 2 are hopelessly intractable.

4. At least two of the following manifestations of overarousal: insomnia, nightmares, irritability, agitation.

5. Exclusion criteria: The above is not due to exacerbation of a mood disorder or ingestion of alcohol or another substance.

Source: Dr. Joiner


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